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Weds 20/03/19 – 4pm to 7pm Young Persons Clinic closed st South Bristol Community Hospital , Sorry.

Clinical Guidance

  • Testing for STIs in primary care

    For detailed instructions on testing for STIs, please see the British Association for Sexual Health and HIV (BASHH) guidance 2015.

    Chlamydia and gonorrhoea testing

     

    The test

    • The test we use in BNSSG is a combined NAAT (Nucleic Acid Amplification test) which tests for chlamydial and gonorrhoeal DNA.
    • The incubation period for chlamydia is up to 2 weeks– do a test at first presentation then repeat 2 weeks later if negative.
    • The incubation period for gonorrhoea is less than 1 week.

     

    Penile sampling

    • For those with male genitalia, the preferred sample is a first catch urine. It is advised urine should be held for at least 1 hour prior to the test.

     

    Vaginal, throat and rectal sampling

    • For those with female genitalia, the preferred sample is a self-taken vulvo-vaginal swab. However, if a speculum examination is being performed for clinical reasons, it is acceptable to take an endocervical sample, then, using the same swab, sample the lower lateral vaginal walls.
    • For men who have sex with men (MSM) we recommend “3 site testing”- this involves a urine sample as usual, plus additional rectal and throat NAAT swabs using the pink swab and orange bottle kits used for those with female genitalia. Make sure these are carefully labelled as to which site is being sampled, as treatment can differ depending on site of infection.
    • When taking a throat swab it is important to roll the swab over both tonsillar fossae and the posterior pharyngeal wall (warn the patient they are likely to gag) to get an adequate sample.
    • The only situation in which we use a throat swab in heterosexual patient is if they have only had oral sex with a partner.

     

    Contacts of infection

    • Patients who are sexual contacts of someone with gonorrhoea should be referred to the sexual health clinic. If they decline to attend it is very important to take a black charcoal culture swab, as well as the NAAT test, to test for antibiotic sensitivities from any exposed sites prior to treatment.

     

    Other testing

    • All patients having an STI screen should be recommended to have blood tests for HIV and syphilis.

     

    Herpes

     

    The test

    • A viral PCR (red topped) swab is used to test for Herpes simplex virus (HSV).

     

    Who to test

    • All genital ulcers should be tested for HSV.

     

    Other tests

    • It is also important to test for syphilis in patient with genital ulceration.

     

    Management

    • If genital herpes is suspected, treatment should commence immediately without waiting for the swab results.

     

    Syphilis

     

    The test

    • Syphilis is diagnosed on a blood test (only one yellow top bottle required for both HIV and syphilis testing).
    • The incubation period for serology testing is up to 3 months. National guidelines recommend repeat testing at 6 weeks and 12 weeks after a ‘high risk’ sexual exposure.

     

    Clinical features

    • The majority of patients with syphilis will not develop clinical features.
    • Although the classic clinical features are genital ulcer (often painless) or macular rash involving palms and soles; any rash may occur.
    • If a patient has an ulcer (chancre) with primary syphilis, the serology may still be negative at that time but should be positive by 2 weeks later.

     

    Other tests

    • All patients having an STI screen should be recommended to have blood tests for HIV and syphilis.

     

    Management

    • Any patients testing positive for syphilis should be referred to Unity Central for assessment, treatment and partner notification.

     

    HIV

     

    The test

    • The fourth generation HIV tests are much more sensitive than the older tests used. The window period has therefore reduced.
    • For a low risk sexual exposure, it is recommended to test at the time of presentation, and repeat again at 4 weeks post-risk.
    • For a high risk sexual exposure, it is recommended to test at the time of presentation, again at 4 weeks and a final confirmatory test at 8 weeks.

     

    Other tests

    • All patients having an STI screen should be recommended to have blood tests for HIV and syphilis (only one yellow top bottle required for both HIV and syphilis testing)

     

    Management

    • Any patients found to be HIV positive should be informed of their result; a confirmatory HIV test should be sent and the patient should be referred to the HIV service
    • If a patient is high risk for HIV, patients can be directed to advice on accessing pre and post-exposure prophylaxis (PEPSE and PrEP) to prevent HIV acquisition.

     

    Hepatitis B

     

    The test

    • Hepatitis B is diagnosed using a blood test.
    • The incubation period for hepatitis B is up to 6 months.
    • To screen for infection: Hepatitis B surface antigen and Hepatitis B core antibody
    • To screen for adequate vaccination: Hepatitis B post-vaccination (surface antibody)

     

    Who to test

    Hepatitis B is a recommended part of sexual health screening for the following groups of patients:

    • Men who have sex with men (MSM)
    • Commercial sex workers
    • People who inject drugs
    • Those who have been sexually assaulted
    • Those born in (or who have a sexual partner born in) a country with high HBV prevalence
    • Those with a sexual partner who is infected with HBV or is at high risk of this
    • Those born to a mother with HBV

    Those who have a risk factor for Hepatitis B (see list above) can be offered vaccination against Hepatitis B. Please see High Risk Groups.

  • Partner Notification: A Guide for Health Professionals

     Introduction

    When a patient is diagnosed with a sexually transmitted infection, it is important to ensure that any sexual contacts are informed.  This helps reduce the spread of infection, reduce risk of health problems for partners and ensure the asymptomatic are aware. The patient should understand the infection, be able to comply with treatment and ensure follow-up arrangements are adhered to. Any patients diagnosed with the following STI’s should have partner notification processes initiated:

    • Gonorrhoea
    • Chlamydia
    • Syphilis
    • Pelvic Inflammatory disease (PID)
    • HIV
    • Hepatitis B
    • Non-Specific Urethritis (NSU)

     

    Approaching Partner Notification

    It is important to take a sexual history from patients diagnosed with a sexually transmitted infection. This serves to identify anybody at risk, relative risk factors in sexual behavior and acts as a cue for the health professional to remind the patient of who needs to be informed and why.

    If the patient is concerned about informing partners, it may help to:

    • Point out the risk of re-infection from untreated partners
    • Make the patient aware that it is likely partners may not have symptoms, so wouldn’t know unless informed
    • Mention that untreated partners may develop long term harm if not informed
    • Reassure the patient that there are multiple ways to approach the topic to partners
    • Inform the patient that their partners have a right to know of any risks to their health

     

    Discuss with the patient how, where and when their contacts may be informed. Discussing the most appropriate time, place and how to broach the topic can help the patient minimise embarrassment. Usual methods of informing partners would be:

    • Face to face
    • Social media message
    • Text message
    • Phone call

    Try to encourage patients to talk to contacts privately, rather than in public or on publicly-viewable media networks. It may help to emphasise not to blame anybody, and to tell partners that they have been to the clinic and have been diagnosed with an infection.

    If the patient specifies the infection to their partners (for example, saying ‘chlamydia’ rather than ‘an infection’) then the partners can access treatment immediately as a contact, rather than getting a test and awaiting a result prior to treatment. This minimises the risk of further transmission or health complications.

     

    Which contacts need to be informed?

    For gonorrhoea:

    • For men with urethral symptoms, any sexual contacts two weeks prior to the onset of symptoms should be informed
    • For asymptomatic men and all women, any sexual contacts within the previous three months should be informed
    • If a patient’s last sexual intercourse was more than eight weeks before the onset of symptoms, then the patient’s most recent sexual partner should be informed and treated.

     

    For chlamydia:

    • In symptomatic men, all contacts within four week prior to the onset of symptoms
    • For all women and asymptomatic men, all contacts within the last six months (or last sexual partner if no contacts within six months).

     

    For syphilis:

    • All sexual partners within the last three months for primary syphilis
    • All sexual partners within two years for secondary and early latent syphilis.

     

    For Non-Specific Urethritis (NSU) or Pelvic-Inflammatory Disease (PID):

    • Four weeks prior to the onset of symptoms in men
    • Six months for women and asymptomatic men, or until the last previous sexual partner (if no contacts within six months)
    • Contact details should be obtained at the first visit as they may subsequently be found positive for chlamydia or gonorrhoea.

     

    For Trichomonas:

    • All current sexual partners should be informed and treated.

     

    For HIV:

    • Sexual partners within the time frame of previous testing results or, if no previous results, then depending on risk assessment by the health professional.

     

    For Hepatitis B:

    • All sexual contacts or needle-sharing contacts within two weeks prior to the onset of jaundice or until surface antigen negative. Consider vaccinating household contacts or providing immunoglobulin to those at immediate risk. Other contacts dependent on risk assessment by the health professional.

     

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